INFECTION PREVENTION AND CONTROL POLICY
Version
7.0
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
1st March 2013
Document Manager (job title)
Consultant Lead Infection Prevention
Date issued
4th March 2013
Review date
March 2015
Electronic location
Corporate Policies
Related Procedural Documents
Infection Control Policies
Key Words (to aid with searching)
Infection control; Infection control committees; Hospital
hygiene; Hospital acquired infection; Hospital cleaning;
Decontamination; Staff health and safety; Risk factors;
Duties; Infection monitoring systems; Risk
management; Training; Clinical guidelines
Infection Prevention and Control Policy. Version 7. February 2013
(Review date: February 2015 unless requirements change)
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CONTENTS
QUICK REFERENCE GUIDE ................................................................................................................ 3
1. INTRODUCTION........................................................................................................................... 4
2. PURPOSE .................................................................................................................................... 4
3. SCOPE ......................................................................................................................................... 4
4. DEFINITIONS ............................................................................................................................... 4
5. DUTIES AND RESPONSIBILITIES ............................................................................................... 5
6. PROCESS .................................................................................................................................... 9
7. TRAINING REQUIREMENTS ..................................................................................................... 10
8. REFERENCES AND ASSOCIATED DOCUMENTATION ........................................................... 11
9. EQUALITY IMPACT STATEMENT ............................................................................................. 12
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ......................................... 13
Infection Prevention and Control Policy. Version 7. February 2013
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QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for those involved in the process to be aware of and follow the detail of this policy.
To ensure there is a robust framework in place for the Prevention and Control of Infection, the Trust
has adopted a number of key approaches
1. There are 12 core clinical protocols for Infection Prevention and Control
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Standard Infection Control Precautions - Standard Precautions Policy for Infection Control
Aseptic Technique– Asepsis Policy
Major outbreaks of communicable disease– Management of Outbreaks of Viral Diarrhoea and
Vomiting, Control of Tuberculosis
Isolation of patients – Isolation Policy
Safe handling and disposal of sharps – Needlestick Sharps Injuries (NSI) & Contamination
Incidents - Prevention and Management
Prevention of occupational exposure to blood-borne viruses including prevention of sharps
injuries– Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and
Management
Management of occupational exposure to blood-borne viruses and post exposure prophylaxis.
– Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and Management
Closure of wards, departments and premises to new admissions. – Management of
Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other
antibiotic resistant micro-organisms
Disinfection Policy. – Decontamination policy
Antimicrobial prescribing – Antimicrobial Prescribing Policy, Antimicrobial Strategy
Reporting healthcare associated infections to the Health Protection Agency as directed by the
Department of Health. –Trust Infection Control Intranet Site
Control of infections with specific alert organisms taking account of local epidemiology and
risk assessment. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the
management of MRSA and other antibiotic resistant micro-organisms
2. The provision of information to patients and visitors
3. An annual infection control assurance framework, in the form of an action plan. Action Plan
Infection Prevention and Control Policy. Version 7. February 2013
(Review date: February 2015 unless requirements change)
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1. INTRODUCTION
Portsmouth Hospitals NHS Trust (the Trust) recognises that it has a duty of care to protect
patients, staff, contractors and visitors from infection and supports the need for effective
systematic arrangements for surveillance, prevention and control. It is therefore committed to
reducing the incidence of healthcare associated infections and, more importantly, maintaining
that reduction.
For many common infections and infectious diseases, early recognition and prompt action can
reduce the spread of disease, the severity of the illness and the number of people infected and
Trust expects its staff to adhere to Infection Prevention Control (IPC) Guidelines to ensure high
standards of care are applied to protect patients, staff and visitors from unnecessary exposure
to infection
2. PURPOSE
The purpose of this policy is to explain the principles of infection prevention and control and to
define the responsibility and accountability of each member of staff in ensuring that those
principles are adhered, so that the Trust can be assured that our prevention and control
measures are robust and appropriate.
3. SCOPE
This Policy applies to all staff, both clinical and non-clinical, employed by Portsmouth Hospitals
NHS Trust, and also to all visiting staff including tutors, students, agency/locum staff and
contractors.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Infection Prevention and Control: processes to prevent and reduce to an acceptable
minimum the risk of the acquisition of an infection amongst patients, health care workers and
any others in the health care setting
Healthcare Associated Infection: any infection that arises as a result of healthcare,
regardless of the care setting. It includes hospital, primary and community care acquired
infections.
Infection: when organisms in or on the body have started to multiply and/or invade a part of the
body where they are not normally found. The body develops a reaction leading to disease or
illness.
Cross Infection: the transfer of organisms from one person to another, this may or may not
lead to illness or disease.
Colonisation: the presence of organisms in or on the body (including wounds), but without any
sign of illness or disease. The body is colonised with many organisms the majority of which
cause no harm and some are actually beneficial.
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Communicable Disease: infection which is capable of spreading from person to person.
Spread of Infection is usually spread by one of the following means: Direct Contact: Contact with contaminated blood, body secretions or fomites
particularly by staff hands that have become contaminated by body to body contact or
the inanimate environment, and by transfusion of contaminated blood
 Indirect Contact: Through equipment, medical devices or processes of care or the
environment in which healthcare is provided.
 Air Borne Spread: contaminated skin scales, aerosol spread via droplets from
coughing and sneezing.
 Vectors: third parties such as mosquitoes, ticks etc can carry infectious agents.
5. DUTIES AND RESPONSIBILITIES
Trust Board
The Trust Board has overall responsibility for ensuring there are effective strategic, corporate
and operational arrangements in place to maintain an effective infection prevention and control
programme and that appropriate financial resources are place to support that programme. To
support this responsibility the Trust Board receives a monthly infection dashboard provided by
the Infection Prevention and Control Data Manager on behalf of the Infection Prevention team
and the Trust.
Infection Prevention Management Committee
The Committee, chaired by the Medical Director in his role as the Director of Infection
Prevention and Control (DIPC), is responsible for:
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Direct the development of infection prevention and control policies, guidelines and
standards
Setting and monitoring local priorities related to infection prevention and control
Ensuring compliance with national standards by development and implementation of
robust monitoring systems across the health community served by the Infection Control
Team
Coordinating and monitoring infection control and prevention activity across the whole
health economy through the implementation of an annual programme of work, in
accordance with national standards and evidence based best practice
Evaluating the impact of infection on service delivery
Directing and supporting the Infection Prevention and Control Team
Identifying organisational learning and development requirements of Trusts across the
whole health economy
Ensuring the effective implementation of the HCAI Plan by receiving and reviewing
progress reports from each division monthly
Receiving and reviewing reports from infection prevention and control projects e.g.
endoscopy and theatre compliance with decontamination and infection prevention and
control standards; making any required recommendations to Trust Boards across the
whole health economy
Reviewing trend analysis from the Infection Prevention and Control Data Manager, of
incidences of sentinel organisms to ensure long term review and, through the Chair,
taking any actions as identified by the trends
Receiving and reviewing reports from the Infection Prevention and Control Team on
adverse incidents and near misses and recommending any change in practice or policy
as highlighted by those reports
Providing Trust Boards across the whole health economy with a bi-annual report on
activity, outcomes and recommendations for change
Through the Chair, providing bi-annual reports to Trusts Board on activity and outcomes
and providing recommendations for each organisation
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Serious Incident Review Group (SIRG)
SIRG provides a high level forum in which to oversee and monitor the reporting and review of
serious untoward incidents, ensuring that recommendations arising from Serious Untoward
Incident investigations are implemented as required and that organisational learning has taken
place. In addition the Group will escalate any appropriate risks to the Risk Assurance
Committee for inclusion on either the Assurance Framework or the Risk Register
Risk Assurance Committee (RAC)
The purpose of the Risk Assurance Committee is to promote effective risk management and to
establish and maintain an assurance framework and a risk register through which the Board
can monitor the arrangements in place to achieve a satisfactory level of internal control, safety
and quality.
CSC Governance Committees
The Committees are responsible for:
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Receiving reports from the Learning and Development Team on staff attendance at
infection prevention and control training
Monitoring compliance with training through ESR.
Continual monitoring of staff attendance at infection prevention and control training, to
ensure compliance
Monitoring any adverse events and near misses1 associated with infection prevention
and control training
Overseeing the implementation of associated action plans
Undertaking monthly reviews of the CSCl risk registers, including the monitoring of risks
identified through the audits of Infection Prevention and Control
Escalating any issues that, for whatever reason, cannot be resolved to the Risk
Assurance Committee for discussion and potential transfer to Trust Risk Register
Learning and Development Team
The Team is responsible for
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Monitoring attendance at Infection Prevention and Control training through the use of
the essential training needs tracker
Providing monthly reports to the CSC Training Groups on staff compliance with infection
prevention and control training for each specialty
Chief Executive:
The Chief Executive has overall responsibility for ensure there are robust processes in place to
ensure effective infection prevention and control procedures are in place but delegates this
responsibility to the Director of Clinical Standards (Medical Director) in his capacity as the
DIPC.
The Medical Director
The Medical Director, in his role as DIPC and Chair of the Infection Control Management
Committee, is responsible for:
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Overseeing the implementation of local infection prevention and control policies and
practices; measuring and assessing their impact and recommending any required
changes
Challenging inappropriate infection prevention and control practice and antibiotic
prescribing decisions
Presenting an annual report for the Trust Board and external stakeholders, on the
organisation’s position in respect of healthcare associated infections
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Consultant Infection Prevention and Control
The Consultant is responsible for:
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The strategic and operational management of infection prevention and control across
the organisation, including management of the Infection Prevention and Control Team
(IPCT) and the production of an annual infection prevention and control programme,
through adoption of national evidence based practice
Providing specialist expert advice and ensuring adequate advice is available to all stall
at all times
Ensuring the development of robust infection prevention and control policies and
practices, including those decontamination
Producing the Annual Trust Infection Prevention and Control Report, including the
annual action plan, to allow this to be presented to the Trust Board by the DIPC, for
onward dissemination through the divisional structures
Infection Prevention and Control Team (IPCT)
The IPCT is responsible for:
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Providing expert reactive and proactive information and advice to all staff, patient,
relatives and carers in respect of healthcare associated infections and the prevention
and control of those infections
Providing a comprehensive infection prevention and control education programme
incorporating induction training, annual mandatory refresher training and education
tailored to the needs of the Trust.
Constantly reviewing the infection prevention and control education programme to
ensure it remains in line with best practice and legislation
Ensuring all policies and guidelines are in line with best practice and legislation
Contributing to the annual infection prevention and control plan, in consultation with the
Infection Control Management Committee and key stakeholder
Contributing to the production of the Annual Report and Infection Prevention and Control
action plan
Collating and reporting MRSA data to the Infection Control Management Committee and
to the Matrons within each division in accordance with national and local requirements,
ensuring thorough and appropriate dissemination of surveillance results
Providing expert management of infection outbreaks / incidents
Advising on aspects of decontamination, including levels of equipment decontamination
and cleaning
Auditing of infection prevention and control practices, and from the result of the audit
developing priorities for targeted surveillance at local level
Reviewing, in collaboration with other, the status of the environment and the
effectiveness of the facilities management services, including cleaning, in order to
provide a safe and clean environment for patient care.
Facilitating the identified and trained group of link staff, ensuring they work within
defined roles and are empowered to continually raise the standards of infection
prevention and control
Reviewing and responding appropriately to adverse incidents / near misses related to
infection prevention and control
Ensuring the provision of information to patients and visitors so that they are aware of
their role in the prevention of healthcare associated infections
Infection Prevention and Control Data Manager
The Manager is responsible for:
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Collating and forwarding the results of all hand hygiene and Infection Prevention and
Control audits to the relevant committees / groups
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Collating information for inclusion in the Annual Trust Infection Prevention and Control
Report, including the annual action plan
Compiling and disseminating data from audits, conducted by the Infection Prevention
Team, throughout the Trust.
Supporting the Infection Prevention practitioners responsible for site surveillance.
Weekly feedback through infection dashboards, infection board reports and running
daily alerts.
Ward / Line Managers
In respect of this policy, managers are responsible for:
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Ensuring dissemination and supporting implementation
Integrating compliance into the Knowledge and Skills Framework and appraisals for all
staff
Ensuring appropriate evidence of compliance is gained during the appraisal process.
Ensuring staff are released for infection prevention and control training
Taking appropriate action following receipt of quarterly report on essential training
attendance to ensure compliance with, and staff attendance at infection prevention and
control training.
Driving a culture of cleanliness and hand hygiene.
Supporting the Link Advisors by ensuring dedicated time for them to undertake their
role in the prevention and control of infection
Ensuring there is adequate training and equipment for staff to safely decontaminate
equipment
Ensuring equipment decontamination is performed in line with local, national and
manufacturers’ guidance
Ensure each ward/area has a designated infection prevention link advisor
Infection Control Link Advisors:
Advisors are responsible for:
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Ensuring they undertake all appropriate training
o The on-line training package
o A bi-annual two-day course delivered by Infection Prevention Control Team for new
link advisors or as a refresher for current advisors every 2-3 years.
o Training sessions 3 times per year
Continually raising the standards of infection prevention and control, including hand
hygiene
Providing infection prevention and control training to colleagues on an ad-hoc basis and
at regular ward meetings.
Ensuring Infection Prevention and Control audits are undertaken.
Ensuring that results of all audits are fed back to the IPCT and to Matrons, through the
CSC structure.
Developing action plans, in conjunction with the IPCT and Matrons; to rectify any
deficiencies highlighted by the audits.
All Staff
All staff are responsible for:
 Ensuring they have received appropriate infection control training in the last twelve
months
 Never knowingly place a patient, member of staff or Trust visitor at risk from an
infection.
 Working to the infection control standards set out in the Trust’s infection control
guidelines and policies,
 Challenging poor infection control practice and seek support from the Infection Control
team as required
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Reporting any adverse incidents in accordance with Trust policy
Reporting any suspected infection outbreaks to the Control of Infection Team
Communicating proactively and reactively with the Infection Control team
Obtaining advice from Occupational Health if they are concerned over their own risks.
Patient Advisory and Liaison Service
The Service is responsible for supporting the Trust’s policies and procedures for Infection
Control and Prevention by advising and influencing the public with regard to hand washing
6. PROCESS
To ensure there is a robust framework in place for the Prevention and Control of Infection, the
Trust has adopted a number of key approaches:
6.1
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Twelve Core Clinical Protocols for Infection Prevention and Control
These protocols form the basis of the Trust’s Infection Control Policy and are:
Standard Infection Control Precautions - Standard Precautions Policy for Infection Control
Aseptic Technique– Asepsis Policy
Major outbreaks of communicable disease– Management of Outbreaks of Viral Diarrhoea and
Vomiting, Control of Tuberculosis
Isolation of patients – Isolation Policy
Safe handling and disposal of sharps – Needlestick Sharps Injuries (NSI) & Contamination
Incidents - Prevention and Management
Prevention of occupational exposure to blood-borne viruses including prevention of sharps
injuries– Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and
Management
Management of occupational exposure to blood-borne viruses and post exposure prophylaxis.
– Needlestick Sharps Injuries (NSI) & Contamination Incidents - Prevention and Management
Closure of wards, departments and premises to new admissions. – Management of
Outbreaks of Viral Diarrhoea and Vomiting, Policy for the management of MRSA and other
antibiotic resistant micro-organisms
Disinfection Policy. – Decontamination policy
Antimicrobial prescribing – Antimicrobial Prescribing Policy, Antimicrobial Strategy
Reporting healthcare associated infections to the Health Protection Agency as directed by the
Department of Health. –Trust Infection Control Intranet Site
Control of infections with specific alert organisms taking account of local epidemiology and
risk assessment. – Management of Outbreaks of Viral Diarrhoea and Vomiting, Policy for the
management of MRSA and other antibiotic resistant micro-organisms
6.2 Information available to patients
Patients and visitors play an important part in the prevention and control of infection. To
enable them to do so, they must be supplied with the appropriate information and support.
The Trust utilizes a number of methods for this, including:
6.2.1
Information available on the internet
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6.2.2
What is Infection Prevention and Control?
Information leaflets: Hand hygiene, ESBL, Clostridium difficile, Influenza, PICC
line, Viral Gastroenteritis, MSSA, Group A Strep, Acinetobacter, E coli.
The Infection Prevention and Control Team
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Leaflets on: Hand hygiene, ESBL, Clostridium difficile, Influenza, PICC line,
Viral Gastroenteritis, MSSA, Group A Strep, Acinetobacter, E coli and other
infections to wards for the use of patients, visitors and staff.
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6.2.3
All patients, visitors and other members of the public are informed, as a
minimum that they must:
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6.2.4
Visit all in-patients with known Clostridium Difficile, MRSA, MSSA, E coli and
other infectious conditions to discuss how this may effect them and their
families and to explain treatments
Participate in partnership groups and public/media forums
Pursue infection prevention forums i.e. twitter, press, internet.
Wash their hands with soap and water or if appropriate apply alcohol gel to
physically clean hands.
Report any concerns or problems they see or experience that may lead to
transmission of infection.
Adhere to all pre-admission advice on how to keep themselves safe from
infection
Wall prompts:
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Red stripes outside clinical areas with alcohol gel attached
Large poster displays in the main entrances
Hand-gel dispensers in the main entrances
6.3 Infection Control Assurance Framework
6.3.1 The Trust’s framework for providing assurance on implementation of required
actions to ensure a safe and clean environment for our patients, staff and visitors
takes the form of an annual action plan. The plan is developed by the Consultant
Infection Prevention and Control and ratified by the Infection Prevention
Management Committee, prior to presentation to the Trust Board
6.3.2
In addition, any issues considered by the Trust Board to be a Prevention and
Control of Infection risk to the achievement of our strategic objectives are placed
on the Trust’s Assurance Framework and Trust Risk Register, which are reviewed
by the Risk Assurance Committee and Trust Board on a monthly basis.
6.4 Managing Risks
6.4.1 Quality assurance processes such as audit, peer review, internal and external
scrutiny are employed to monitor the level of risk, against defined national and
local infection control standards
6.4.2
Any identified risks are placed on the CSC Risk Registers, which are reviewed
monthly at the CSC Governance Committees; for progress against the action
plans developed to mitigate or resolve the risks
6.4.3
CSCs are required to report on the management of risks:
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6.4.4
Via the Trust heatmap.
At performance reviews, chaired by the Chief Nurse
Any risks that cannot, for whatever reason, be managed locally are escalated to
the Risk Assurance Committee for discussion and potential inclusion on the Trust
Risk Register of Board Assurance Framework
7. TRAINING REQUIREMENTS
7.1 Prevention and Control of Infection forms part of the Trust’s Core Essential Skills and
Training requirements, as identified by the Training Needs Analysis
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7.2 Prevention and Control of Infection training forms part of mandatory Trust induction
7.3 All staff are required to undergo annual Prevention and Control of Infection updates. This
is provided either by direct teaching or E-learning
7.4
Ad hoc Prevention and Control of Infection training is provided by Infection Prevention and
Control by drop-in sessions and audit days. This is supplemented by the Link Advisors as
part of regular ward meetings.
7.5 The uptake of training is tracked by the Learning and Development Team, using the
Essential Training Needs Tracker and attendance is monitored through quarterly reports
produced by the Team and disseminated through the divisional structure
7.6 Ward and Line Managers are responsible for ensuring that any staff members who do not
attend this mandatory training are followed up on an individual basis.
7.7 The requirement for Infection Prevention and Control is also integrated into the
Knowledge and Skills Framework and monitored through the staff appraisal process
In addition, awareness is raised through:
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Participation in National Infection control week
Participation in specialty specific days e.g. National Rheumatology Day
Trust Hand Hygiene for the public and other visitors is included as part of the Trust
open day
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Department of Health (2002 a) Getting ahead of the curve: action to strengthen the
microbiology function in the prevention and control of infectious diseases. London. HMSO.
Department of Health (2003) Winning Ways: Working together to reduce healthcare associated
infection in England. London. HMSO.
Department of Health (2004) Standards for Better Health. London. HMSO.
Department of Health (2004) A matron’s charter: An action plan for cleaner hospitals London.
HMSO
Department of Health (2004) Towards cleaner hospitals and lower rates of infection. London.
HMSO
Department of Health (2005) Saving Lives: a delivery programme to reduce Healthcare
Associated Infection including MRSA. London. HMSO
Department of Health (2006) Going further faster: Implementing the Saving Lives delivery
programme. London. HMSO.
Department of Health (2008) The Health and Social Care Act 2008: Code of practice on the
prevention and control of infections and related guidance.
Department of Health (2010) Equity and Excellence: Liberating the NHS.
Infection Control Nurse Association (2004) Audit tools for monitoring infection control standards
2004.
National Institute for Clinical Excellence (2003) Infection Control: Prevention of healthcareassociated infections in primary and community care. www.nice.org.uk/pdf/Infection
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9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
As a minimum the following elements will be monitored to ensure compliance.
Minimum requirement to
be monitored
Lead
Tool
Frequency of
Report of
Compliance
Reporting arrangements
Regular attendance at
IPMC meeting
Caroline
Mitchell
CSC representation
log
Quarterly
Infection Prevention
attendance at other Trust
forums i.e. RAC, SIRG
Caroline
Mitchell
CSC representation
log
As required
Infection Prevention and
control protocols
Caroline
Mitchell
Infection Prevention
and Control report
Annually
Infection Prevention
Management Committee
CSC leads
Infection Prevention and
control training
Lynn Hansell
Essential training
needs tracker
Monthly
Monthly reports to the CSC
training groups
CSC leads
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Infection Prevention Management
Committee
Lead(s) for acting on
Recommendations
CSC leads
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